“in-State health care
provider” means an individual or entity, including, but not limited to, a
physician or other health care professional licensed pursuant to Title 45 of
the Revised Statutes, and a hospital or other health care facility licensed
pursuant to Title 26 of the Revised Statutes that is not an out-of-State health
care provider.

“out-of-State health care
provider” means an individual or entity providing health care services at a location
outside the geographic boundaries of this State.

“primary care" means the
provision of preventive, diagnostic, treatment, management, and reassessment
services to individuals in facilities providing family practice, general
internal medicine, general pediatrics, and routine obstetrics/gynecology.

"reasonably
proximate" means a geographic distance from the covered person's place of
residence that does not exceed 25 miles.

“tertiary
care” means specialized care performed by specialists
working in an inpatient or outpatient facility for special investigation and
treatment of complex diseases or conditions.

b. Notwithstanding the
provisions of any other law to the contrary, a carrier which offers health
benefits coverage under the State Health Benefits Program, School Employees’
Health Benefits Program, or any self-insured plan or plan offered to public
employees or retirees outside the State Health Benefits Program or the School
Employees’ Health Benefits Program, to an employee or retiree and any dependent
eligible for such health care benefits coverage, shall only provide coverage
for medically necessary health care services provided by an out-of-State health
care provider as specified in subsection c. of this subsection, except for
coverage authorized pursuant to subsection f. or g. of this section.

c. Medically necessary
tertiary health care services may be performed by an out-of-State specialty or
subspecialty health care provider when there is no in-State health care
provider reasonably available to treat the particular condition based on an
expedited determination by the carrier and the State Health Benefits
Commission, the School Employees’ Health Benefits Commission or the plan
administrator, as the case may be, in consultation with the Department of
Health and Senior Services, that such service is not otherwise available
through an in-State health care provider or where there is no in-network
provider who is reasonably proximate to the covered person’s place of
residence.

d. (1) The out-of-State
health care provider shall receive reimbursement for out-of-network charges at the
lesser of the contractual rate or a rate equal to 150% of the Medicare fee
schedule for those same services.

(2) The employee or retiree
shall be responsible for the entire balance of the out-of-State health
provider’s charges that exceed the applicable out-of-network reimbursement.

e. The carrier shall
establish preauthorization or review requirements of the health benefits plan
regarding the determination of medical necessity for the employee, retiree, or
covered dependent to access out-of-State benefits, as set forth in writing
pursuant to section 5 of P.L.1997, c.192 (C.26:2S-5), with which the covered
person shall comply as a condition of receiving benefits pursuant to this
section.

f. This section shall not
apply to: (1) emergency care; (2) primary care; (3) an employee, retiree, or
covered dependent who has his or her principal residence outside of this State
or is enrolled as a full-time student at a school located outside this State
and resides outside this State while attending that school, or (4) such other
unusual and compelling circumstance determined by the State Health Benefits Commission,
School Employees’ Health Benefits Commission or the plan administrator, as the
case may be, in consultation with the Department of Health and Senior Services,
that warrants an individualized exception from the requirements of this
section. For the purposes of this subsection, a person will be deemed to have
his principal residence outside this State if all of the following conditions
are met: the person spends the majority of his or her nonworking time outside
the State, and resides at a location outside the State which is clearly the
center of his or her domestic life, and has designated the out-of-State
residence as his or her legal address and legal residence for voting.

g. This section shall not
apply to cases when it is medically necessary for the employee, retiree, or
covered dependent to continue current treatment with the out-of-State health care
provider or under the following circumstances: (1) in cases of the pregnancy
through the postpartum evaluation, up to six weeks after delivery; (2) in the
case of post-operative care, up to six months following the surgical procedure;
(3) in the case of oncological treatment, up to one year following the first
date of treatment; and (4) in the case of psychiatric treatment, up to one year
following the first date of treatment.

h. Notwithstanding the
provisions of another law to the contrary, the State Health Benefits Plan
Design Committee, the School Employees’ Health Benefits Plan Design Committee,
and any public employer shall provide to employees the option to select a
single plan that shall not limit coverage for medically necessary health care
services provided by an out-of-State health care provider pursuant to this
section. Each employee or retiree who selects coverage under the plan shall pay
the additional portion of the premium or periodic charge associated with
selecting a plan that does not limit coverage for medically necessary health
care services provided by an out-of-State health care provider for health care
benefits provided to the employee, retiree, and dependents covered under the
plan.

i. This section shall be
operative January 1, 2012.]

a. Notwithstanding the provisions
of any other law to the contrary, beginning January 1, 2012, the State Health
Benefits Plan Design Committee, the School Employees’ Health Benefits Plan
Design Committee, or any public employer that offers health benefit plans to
public employees, retirees, and any dependent thereof, shall offer at least one
health benefit plan to plan participants that shall include only in-State
health care providers and that shall be subject to the requirements set forth
in subsections b. through f. of this section and shall offer at least one
health benefit plan to plan participants that shall include out-of-State health
care providers and that shall not be subject to the requirements set forth in
subsections b. through f. of this section. Each plan participant who selects
coverage under a plan that includes out-of-State health care providers is not
subject to the requirements of subsections b. through f. of this section and shall
pay any additional premium or periodic charge associated with selecting that
plan.

b. As used in this section:
"emergency care” means immediate treatment provided in response to a
sudden, acute and unanticipated medical crisis in order to avoid injury,
impairment, or death.

“in-State health care provider” means
an individual or entity, including, but not limited to, a physician or other
health care professional licensed pursuant to Title 45 of the Revised Statutes,
and a hospital or other health care facility licensed pursuant to Title 26 of
the Revised Statutes that is not an out-of-State health care provider.

“out-of-State health care provider”
means an individual or entity providing health care services at a location
outside the geographic boundaries of this State.

“primary care" means the
provision of preventive, diagnostic, treatment, management, and reassessment
services to individuals in facilities providing family practice, general internal
medicine, general pediatrics, and routine obstetrics/gynecology.

"reasonably proximate"
means a geographic distance from the covered person's place of residence that
does not exceed 25 miles.

“tertiary care” means specialized
care performed by specialists working in an inpatient or outpatient facility
for special investigation and treatment of complex diseases or conditions.

c. A carrier which offers health
benefits coverage under an in-State only plan shall only provide coverage for
medically necessary health care services provided by an out-of-State health
care provider as specified in subsection d. of this subsection, except for
coverage authorized pursuant to subsection e. or f. of this section.

d. Medically necessary tertiary
health care services may be performed by an out-of-State specialty or
subspecialty health care provider when there is no in-State health care
provider reasonably available to treat the particular condition based on a
certification from a physician licensed in New Jersey that expresses his or her
professional opinion that such medical care or technology is not otherwise
available through a qualified in-State health care provider, or when there is
no in-State health care provider who is reasonably proximate to the covered person’s
place of residence. A physician who knowingly signs a false certification in
accordance with this section shall be subject to disciplinary action and civil penalties pursuant to sections 8 and 9
of P.L.1978, c.73 (C.45:1-21 and 22).

e. Subsections b. through d. of this
section shall not apply to: (1) emergency care; (2) primary care; or (3) such
other unusual and compelling circumstance determined by the State Health
Benefits Commission, School Employees’ Health Benefits Commission or the plan
administrator, as the case may be, in consultation with the Department of
Health and Senior Services, that warrants an individualized exception from the
requirements of this section.

f. Subsections b. through e. of this
section shall not apply to cases when it is medically necessary for the
employee, retiree, or covered dependent to continue current treatment with the
out-of-State health care provider, or when the employee, retiree, or covered
dependent has been receiving tertiary care from an out-of-State health care
provider prior to the enactment of P.L. , c. (now pending
before the Legislature as this bill) until the course of treatment is
concluded.

This bill requires that,
beginning January 1, 2012, the State Health Benefits Plan Design Committee, the
School Employees’ Health Benefits Plan Design Committee, or any public employer
that offers health benefit plans to public employees, retirees, and any
dependent thereof, offer at least one health benefit plan to plan participants
that will include only in-State health care providers and that will be subject
to certain requirements, and at least one health benefit plan to plan
participants that will include out-of-State health care providers and that will
not be subject to certain requirements.